Wait Until Dark — Night Eating Syndrome
Today’s Dietitian
By Mary Kaye Sawyer-Morse, PhD, RD
Vol. 6, No. 8, p. 28

This is not your occasional midnight snack. Night eating syndrome is a persistent and troubling disturbance in eating patterns.

Night has fallen and the house is quiet except for the soft thump of a refrigerator door closing. Its light illuminates a dark, empty kitchen—except for the solitary eater. Kathy* doesn’t eat much during the day and instead finds herself eating most of her daily intake of food in the evening and late at night. She describes her life as stressful; Kathy is a single parent with two children and a demanding job. She would like to lose the 40 pounds she has gained over the past couple of years but is depressed and feels her situation is hopeless.

Defining Night Eating Syndrome
Kathy’s situation is typical of someone experiencing night eating syndrome (NES). NES may include morning anorexia with evening hyperphagia and sleep disturbances but has not yet been formally defined as an eating disorder, according to Anorexia Nervosa and Related Eating Disorders, Inc. The syndrome is thought to be caused by a combination of biological, genetic, and emotional factors with some research indicating that the night eater may be suffering from a failure of the body to respond appropriately to stress.1
The signs and symptoms of NES include the following:
• Not feeling hungry in the morning. Typically the person has little or no appetite for breakfast and delays the first meal for several hours after waking.
• Overeating in the evening. In contrast to a lack of appetite in the morning, the person consumes more than one-half of his or her daily food intake after dinner but before breakfast and often has more food after dinner than during that meal.
• Difficulty falling asleep. The individual finds it hard to fall asleep. He or she may toss and turn for some time and feel a need to eat something just before going to bed to help him or her fall asleep faster.
• Waking at night and eating. The person may wake at least once during the night and find it necessary to eat before being able to fall asleep again.
• The eating produces feelings of guilt and shame, not enjoyment.
• Feeling depressed. In addition to eating and sleeping problems, the individual may feel sad or disconsolate. Especially at night, the individual may be moody, tense, anxious, or agitated.

Not familiar with NES? Not surprising. While the syndrome was first described in 1955, it frequently goes unrecognized by healthcare professionals. NES is not simply bad habits. As stated above, it includes disordered eating and sleep and mood disorders. And it doesn’t only occur among people who are obese—until recently, that was the widespread supposition. Interestingly, Marshall et al noted in their recent study findings that NES also occurs among nonobese persons.2

The Consequences
Overeating resulting from NES can lead to weight gain and a variety of associated health conditions. It is estimated that between 9% and 15% of individuals seen in weight treatment programs are suffering from NES.3 This percentage increases to almost 30% for those severely overweight (100-plus pounds) and includes individuals who have been evaluated for surgical treatment for obesity.4

In addition to weight-related health issues—type 2 diabetes, high blood pressure, arthritis, and heart disease—daytime sleepiness can be a very real problem. Excessive sleepiness can affect overall concentration and the ability to perform everyday activities.
Another common problem among night eaters is depression. Some sufferers complain of long-term struggles with feeling sad. Studies conducted at the University of Pennsylvania indicate that approximately 45% of NES participants had experienced a major depressive episode at some point in their lives.5

Stress is yet another issue. Life stress events are frequently associated with the onset of night eating. Allison et al noted that up to 75% of sufferers describe how a specific stressful event played a role in either the initiation or continuation of NES.5

Night Eating Patterns
NES can assume a number of different forms or patterns. The authors of the book Overcoming Night Eating Syndrome: A Step-By-Step Guide to Breaking the Cycle discuss four different types of night eaters:
• the compelled evening and nighttime overeater;
• the anxious/agitated night eater;
• the cravings night eater; and
• the all-or-nothing belief about sleep night eater.6

The compelled evening and nighttime overeater is described as someone who doesn’t get up to eat in the middle of the night but does consume most of his or her calories in the evening and nighttime. Often, the individual will stay up late and continue eating after the evening meal.

In contrast, the anxious/agitated night eater wakes up at night plagued with anxiety-provoking thoughts that create stress and agitation. For this type of eater, the physical agitation directs his or her to food as a means to calm down.

The cravings night eater experiences overwhelming food cravings. For this individual, eating a certain food is the primary goal, not so much whether or not it will help facilitate sleep. After having the desired food, he or she will frequently experience remorse, guilt, and even physical distress.

Finally, the fourth type of night eater—described as the all-or-nothing belief about sleep night eater—is concerned about not getting enough sleep. In this pattern, the person is focused on sleep, not food. When the person wakes up in the middle of the night, he or she uses food as a means to help get back to sleep with the belief that eating will help him or her relax and thus aid in achieving better sleep.

Making the Connection
Regardless of the night eating pattern, finding the connection between thoughts and resulting behavior is key. In other words, while eating at night may appear to be automatic, it has somehow become embedded in the nightly behavior routine. By exploring the links in the behavior chain, a person is able to see how one response produces the stimulus for the next response. An example of a chain would be waking up at night, looking at the clock and becoming anxious about not getting enough sleep, getting out of bed, going to the refrigerator, choosing to have something to eat, feeling calmer and sleepier, and going back to bed.

The goal is to become aware of the chain components and begin to break them. Changing behavior can be difficult. Keeping a journal can be an important tool to help discover these connections. At the beginning of this process, the person may feel he or she has limited ability to control food choices. The first step in behavior change is raising the level of awareness of the behavior. In other words, a person with increased awareness may be able to say, “Isn’t it interesting that I always choose cookies, breads, and cereals rather than salad or croutons when I eat in the middle of the night? I guess my behavior isn’t as automatic as I thought. I could choose other options.”

Managing the Midnight Munchies
It’s 1 am and Kathy is sitting at the kitchen table. She’s hungry and restless as she struggles with a familiar internal dialogue: “I can’t sleep if I’m hungry.” “I’ve followed my diet all day and I need a treat.” “I’ll only choose low-calorie, healthy foods. A little bit won’t hurt.” Kathy might find it helpful to explore her reasons for eating—her behavior chain—and then choose the most healthful action. She might:
• Determine what she is really feeling and thinking and then decide what action would meet that need. For example, if she is not truly hungry, what is the reason she wants a snack? Is it because a favorite food is in sight? If so, keeping the food out of the house might be an answer. Or is it because she is lonely? Then making plans to visit a friend could be part of the solution.
• After assessing her reasons for wanting to eat, she could think of something else to do for 15 or 20 minutes (like reading, stretching, or writing a note to a friend). By allowing time between the food craving (thought) and actually eating, she may find that the craving has passed.
• If her food cravings are still strong after waiting the brief time period, she could decide to have a small portion of the desired food or try a new, lower-calorie substitute. Buying food in preportioned amounts or preportioning them once at home helps control overeating. By limiting the amount consumed late at night, she can wake up hungry in the morning and start the day with a satisfying breakfast.
• Add exercise to the evening schedule. A walk after dinner, water aerobics, or a Tai Chi class might help alleviate stress and promote more restful sleep as long as they are done early enough in the evening. Vigorous exercise in the late evening may actually increase sleeplessness.
• Practice deep breathing. Diaphragmatic breathing exercises (breathing deeply with abdominal muscles) can be especially helpful in reducing anxiety and agitation. Deep, relaxed breathing also helps promote restful sleep.

Anne M. Fletcher, MS, RD (author of the Thin for Life books), suggests that since NES has probably existed for some time, it may be unrealistic to expect the individual to break it completely. She notes that an evening snack (300 calories or less), if planned as part of the total day’s calories, can be part of healthful eating. Fletcher also recommends implementing a ritual or “meal-termination technique”—something that symbolizes the end of the meal. This might be having a cup of favorite tea, a brief prayer of thanks, or a short walk after the evening meal. A ritual helps the individual transition from one behavior (eating) to another behavior (eg, rest, preparation for bed).

While new ideas are forthcoming to help manage NES (eg, selective serotonin reuptake inhibitors), much of the answer rests in developing increased self-awareness and effective self-management tools and techniques. One treatment approach is unlikely to meet the needs of every person experiencing night eating. Successful control of night eating comes through the exploration of unique individual needs and stressors and finding multiple solutions for developing healthful eating.

* Fictitious name

— Mary Kaye Sawyer-Morse, PhD, RD, professional speaker and author, is owner and education director of The Center for Success, a Texas-based company that provides keynotes, in-service training, and seminars to diverse industries. Her areas of expertise include life-work balance, creating behavior change, women’s health issues, and understanding nutrition/health research.

References for this article are available upon request by e-mailing TDeditor@gvpub.com.

Resources
Weight and Eating Disorders Organizations
Academy for Eating Disorders
www.aedweb.org
The academy is an international organization with members from the research and clinical community. They publish the International Journal of Eating Disorders.

Anorexia Nervosa and Related Eating Disorders, Inc. (ANRED)
www.anred.com
ANRED is a not-for-profit organization that has included the definition for NES on its Web site. ANRED provides information about many aspects of eating and weight disorders.

North American Association for the Study of Obesity
www.naaso.org
This organization publishes the journal Obesity Research. The Web site provides helpful information about obesity and related problems.

Promoting Restful Sleep
National Center on Sleep Disorders
www.nhlbi.nih.gov/about/ncsdr/
This site provides information regarding ongoing research into sleep disorders. It also lists resources for the public.

National Sleep Foundation
www.sleepfoundation.org
This foundation provides information about problems with sleeping and has an easy-to-use guide to sleep services nationwide.

Help With Stress
The National Institute for Occupational Safety and Health (NIOSH)
www.cdc.gov/niosh/stresswk.html
NIOSH is the federal agency responsible for conducting research and making recommendations for the prevention of work-related illness and injury (including stress-related problems).

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